What's behind your eosinophilic myocarditis? A case of Churg–Strauss syndrome diagnosed during acute heart failure

Abstract

Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare multisystem disorder; cardiac involvement may include eosinophilic myocarditis. A 67-year-old woman presented with 1-week history of dyspnoea and orthopnoea. She had a history of adult-onset asthma and peripheral eosinophilia. The investigations showed T-wave inversion on lateral leads, peripheral eosinophilia, elevated troponin and BNP values, and severe biventricular systolic dysfunction with diffuse hypokinesia and apical akinesia. Computed tomography excluded coronary disease and showed bilateral basal ground-glass opacities, air-space consolidation, and bilateral reticular-nodular pattern. Cardiac magnetic resonance findings were compatible with active myocardial inflammation. An endomyocardial biopsy (EMB) confirmed the diagnosis of eosinophilic myocarditis, and a therapy with oral corticosteroids and heart failure medications was started.

Cardiac magnetic resonance in histologically proven eosinophilic myocarditis

“…Prior to our work, only solitary case reports existed on CMR imaging in histology-proven EM [ 5 – 16 ]. Recently, Antonopoulos et al [ 24 ] reported CMR findings in a large retrospective cohort of patients with peripheral eosinophilia, but the histologic equivalents of imaging characteristics could not be confirmed as myocardial biopsies were not done.…”

“…Recently, Antonopoulos et al [ 24 ] reported CMR findings in a large retrospective cohort of patients with peripheral eosinophilia, but the histologic equivalents of imaging characteristics could not be confirmed as myocardial biopsies were not done. The earlier case studies [ 5 – 16 ] showed CMR abnormalities varying by the etiology of EM. Marked subendocardial LGE, with or without intracavitary thrombus, appeared typical for cases of chronic eosinophilia [ 8 – 10 , 15 ], while more acute cases were often associated with myocardial edema, prolonged values of T1 and T2, and patchy LGE that was predominantly subepicardial [ 5 , 6 , 11 ] but could involve LV subendocardium as well [ 12 ].…”

“…It can reveal myocardial edema and injury, the hallmarks of acute myocarditis, as well as ventricular dysfunction, pericardial effusion, and intra-cavitary thrombosis, all potentially associated with EM. Due to the rarity of EM, only solitary case-reports exist on CMR findings in histologically proven EM [ 5 – 16 ]. To add insight into the yield of CMR in EM, we identified and systematically re-analyzed all CMR studies from patients with histologically proven EM seen over two decades at our center.…”